Claims & Appeals

  • Submitting Claims

    As a participating provider with SWH of MA, you have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered healthcare services unless otherwise specified under your Participating Agreement. The rates established in your Participating Agreement are considered full payment for covered services provided. Accordingly, SWH of MA members may not be balance billed for any remaining amounts and/or difference between what is billed, and your negotiated reimbursement rates defined in the rate exhibit of your Participating Provider Agreement.

    Senior Whole Health of Massachusetts pays clean claims submitted for covered services provided to eligible members. Ninety percent (90%) of all Clean Claims from Providers, who are an individual or group practice or who practice in shared health facilities, are paid within thirty (30) Calendar Days of the date of receipt.

     

    How do I submit my claims to Senior Whole Health of Massachusetts?

    We recommend that you submit claims through the Electronic Data Interchange (EDI) for efficient processing and payment. We work with Change Healthcare for all EDI transactions.

    When submitting your 837 (I & P) files, please use our Payer ID: SWHMA

    Learn more about EDI

    Submitting Electronic Claims

    SWH offers a direct submit/web-based claims option through Availity. This functionality is available via the provider portal on our website. There is no charge to participating providers for submitting claims through the Availity tools. Availity supports keyed entry of claims on the portal and supports secure transfer/upload of batch claim files from most practice management systems. You must register with Availity to use the service and add SWH as one of your payers. If you are not currently registered with Availity please visit Availity to get connected.

    Submitting Paper Claims

    To submit paper claims, please mail to:

    Senior Whole Health of Massachusetts
    PO Box 22640
    Long Beach, CA 90801

    In order to accurately process paper claim submissions, a provider must bill on acceptable claim forms to ensure accuracy of the data being input into our systems. CMS guidelines state: “For both CMS-1500 and UB-04 Claims, the only acceptable claim forms are those printed in Flint OCR Red, J6986, (or exact match) ink. Although a copy of the CMS- 1500 and UB-04 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. Please resubmit on red-lined form." Change Healthcare will begin to reject claims starting 10/1/22 If you have question, contact the claims department at (855) 838-7999. Processing and payment of claims for covered services are generally made within 30 calendar days of receipt of a clean claim. For more information on claims submission and payment, please refer to the SWH of MA Provider Manual.
  • Submitting Appeals on Behalf of Your Patients

    Provider may file appeals and/or grievances on behalf of a Senior Whole Health of Massachusetts member with the member’s written consent.

    To file an appeal or grievance:

    • Call: (855) 838-7999/ (888) 794-7268
    • Fax: (562) 499-0610
    • Mail: Senior Whole Health of Massachusetts, Inc.
    • Attn: Grievance and Appeals
      P.O. Box 22640
      Long Beach, CA 90801

     

    We will make our appeal decision and send to you in writing within 30 days of receipt of the request. Expedited appeals will be resolved within 72 hours.

    A grievance on behalf of a SWH of MA member must be filed within 60 days of the event. We resolve routing complaints immediately. However, we may need to ask you to submit additional information. In that case, you will have 14 days to get us the information. We will notify the member and/or the representative within 30 days of the grievance filing or 44 days if an extension was granted.